Annals for Educators - January 2023
Authors: Christine Laine
Journal: Annals of Internal Medicine (2023)

Web ExclusivesJanuary 2023Annals for Educators - January 2023FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202301170 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsOutpatient Treatment of Confirmed COVID-19: A Living, Rapid Review for the American College of PhysiciansOutpatient Treatment of Confirmed COVID-19: Living, Rapid Practice Points From the American College of Physicians (Version 1)Ongoing Need for Clinical Trials and Contemporary End Points for Outpatient COVID-19The first article reports the results of a living, rapid review that assessed the benefits and harms of different COVID-19 treatments in the outpatient setting. The second article presents living, rapid practice points developed by the Scientific Medical Policy Committee of the American College of Physicians (ACP) to summarize the best available evidence on the treatment of adults with confirmed COVID-19 in the outpatient setting. In the accompanying editorial, the editorialists commend the authors of the review and the practice points for trying to summarize the rapidly evolving literature, and they discuss the challenges of updating reviews and associated recommendations as new evidence emerges and relevant outcomes evolve.Use these articles and the editorial to:Watch the brief video summarizing the systematic review with your learners. Discuss the issues raised in the editorial and how they should be addressed in the update of these “living, rapid” documents.Ask your learners to describe patients with COVID-19 they have encountered who required only outpatient care. Review factors that identify patients at high risk for progression to severe disease.Review the drugs that ACP recommends against using to treat outpatients with COVID-19. Have your learners discuss how they would respond to a patient requesting ivermectin.Review the drugs that ACP recommends using to treat outpatients with COVID-19. Have an infectious disease specialist join your session to review procedures at your institution for obtaining these therapies.Visit this page to review a tool for examining drug interactions with nirmatrelvir–ritonavir (Paxlovid) that must be considered when using the drug for outpatient treatment of COVID-19. Effect of Calorie-Unrestricted Low-Carbohydrate, High-Fat Diet Versus High-Carbohydrate, Low-Fat Diet on Type 2 Diabetes and Nonalcoholic Fatty Liver Disease. A Randomized Controlled TrialWhether a low-carbohydrate, high-fat diet is a possible treatment strategy for type 2 diabetes is unclear. This trial examined whether a low-carbohydrate, high-fat diet without a recommendation to restrict calories is more effective than a high-carbohydrate, low-fat diet at improving glycemic control, metabolic markers, and nonalcoholic fatty liver disease.Use this article to:Invite a dietitian to your session to review the composition of the diets studied in this trial and to provide practical suggestions and resources to use when advising patients to follow one of these diets.Calorie restriction was not a component of the dietary interventions in this study. Discuss whether calorie intake might nevertheless have played a role in the differences observed in this study.Discuss the challenges in conducting randomized trials of dietary interventions.Given the results of this study, ask your learners what type of diet they would advise patients with type 2 diabetes and nonalcoholic fatty liver disease to follow.Nirmatrelvir Plus Ritonavir for Early COVID-19 in a Large U.S. Health System. A Population-Based Cohort StudyNirmatrelvir Plus Ritonavir for Ambulatory COVID-19: Expanding Evidence, Expanding RoleThe clinical impact of coadministration of nirmatrelvir and ritonavir among vaccinated populations is uncertain. This study emulated a clinical trial to assess whether nirmatrelvir plus ritonavir reduces risk for hospitalization or death among outpatients with early COVID-19 in the setting of prevalent SARS-CoV-2 immunity and immune-evasive SARS-CoV-2 lineages. The authors of the accompanying editorial believe that the uptake of nirmatrelvir plus ritonavir is suboptimal in ways that increase disparities and that this study should motivate rectifying that.Use this article and the editorial to:Ask your learners about the types of patients for whom they would recommend treatment with nirmatrelvir–ritonavir.Discuss the absolute and relative differences reported and how emphasizing one versus the other might affect enthusiasm for use of the drug. Ask your learners which result they would use when discussing nirmatrelvir–ritonavir with a vaccinated patient.Ask your learners to brainstorm about strategies to improve equitable use of nirmatrelvir–ritonavir.Visit this page to review a tool for examining drug interactions with nirmatrelvir–ritonavir that must be considered when using the drug for outpatient treatment of COVID-19. Left Atrial Mechanical Dysfunction and the Risk for Ischemic Stroke in People Without Prevalent Atrial Fibrillation or Stroke. A Prospective Cohort StudyAtrial myopathy is characterized by changes in left atrial function and size and may promote atrial fibrillation and cardiac thromboembolism. This study assessed the association between echocardiographic measures of left atrial function and ischemic stroke and examined whether they can improve stroke prediction beyond that achieved by the CHA2DS2-VASc score variables.Use this article to:Review the CHA2DS2-VASc score with your learners.Invite a cardiologist to your session to review and demonstrate the echocardiographic measures found to be associated with increased risk for stroke in this study.Discuss which patients might benefit from echocardiography to evaluate left atrial function.Long-Term Stability of Coverage Among Michigan Medicaid Beneficiaries. A Cohort StudyThe Stability and Continuity of Medicaid CoverageMedicaid, the primary source of insurance coverage for disadvantaged Americans, was originally designed as a temporary safety-net program. This study used a 10-year longitudinal panel of Michigan Medicaid eligibility data to assess patterns of short- and long-term enrollment among beneficiaries. The author of the accompanying editorial anticipates the greatest loss of health insurance in U.S. history with the expiration of federal COVID-19 relief legislation, which created a temporary nationwide moratorium on disenrolling Medicaid beneficiaries.Use this article and the editorial to:Invite a social worker to your session to review the qualifications for Medicaid in the geographic area served by your institution.Discuss how expiration of federal COVID-19 legislation is likely to affect insurance coverage among the patient populations served by your institution.Effectiveness of an Intervention to Improve Decision Making for Older Patients With Advanced Chronic Kidney Disease. A Randomized Controlled TrialShared Decision Making for Older Adults: Time to Move Beyond Dialysis as a DefaultMany patients are not well informed about treatment options for kidney failure. This trial assessed the use of a decision aid on treatment options for older persons with advanced chronic kidney disease and reports on changes in decisional conflict, knowledge, and uncertainty. The authors of the accompanying editorial view the results as promising but emphasize the need for more effective tools that move kidney disease decision making for older patients beyond dialysis as a default option.Use this article and the editorial to:Invite a nephrologist to your session to review the indications for renal replacement therapy, the various types of renal replacement therapy that are currently available, and those that are on the horizon.Discuss what the researchers mean by “decisional conflict,” one of the main outcomes examined in this study. Ask your learners to describe scenarios in which decisional conflict regarding renal replacement therapy is high or low.Discuss the barriers to use of decision aids such as the one used in this study. How might these barriers be overcome?MigraineMigraine affects approximately 1 billion people worldwide, with up to 15% of adults in the United States having migraine attacks in any given year. More than 90% of patients with recurrent headache presenting to primary care offices and emergency departments have migraine. Migraine is associated with high socioeconomic and personal impact; it is the second leading cause of years lived with disability worldwide for all ages and the leading cause in women aged 15 to 49 years. Diagnostic uncertainty increases the likelihood of unnecessary investigations and suboptimal management. This In the Clinic article advises clinicians about diagnosing migraine; ruling out secondary headache disorders; developing treatment plans that may include self-management, nonmedication treatments, acute medications, and preventive medications; and deciding when to refer a patient to a specialist.Use this article to:Invite a neurologist to your session to review how to diagnose migraine and the various treatment options.If any of your learners suffer from migraine, ask for volunteers to describe what a migraine headache feels like for them.Ask your learners to describe appropriate follow-up of patients with migraine. How often should they be seen? Should any tests be done routinely?Test your learners' knowledge by having them complete the quiz that accompanies the article and then reviewing the correct answers.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Christine Laine, MD, MPHFrom the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics January 2023Volume 176, Issue 1 ePublished: 17 January 2023 Issue Published: January 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...